Cognitive predictors of understanding treatment decisions in patients with newly diagnosed brain metastasis

Abstract

Background Medical decision-making capacity is a higher-order functional skill that refers to a patient’s ability to make informed, sound decisions related to care and treatment. In a medical context, understanding is the most cognitively demanding consent standard and refers to a patient’s ability to comprehend information to the extent that informed decisions can be made. Methods The association between reasoning and cognition was examined using data from 41 patients with diagnosed brain metastasis. All diagnoses were made by a board-certified radiation oncologist and were verified histologically. In total, 41 demographically-matched, cognitively healthy controls were also included to aid in classifying patients with brain metastasis according to reasoning status (i.e., intact or impaired). Results Results indicate that measures of simple attention, verbal fluency, verbal memory, processing speed, and executive functioning were all associated with understanding, and that verbal memory and phonemic fluency were the primary cognitive predictors. Using these two primary predictors, equations can be constructed to predict the ability to understand treatment decisions in patients with brain metastasis. Conclusions Although preliminary, these data demonstrate how cognitive measures can estimate understanding as it relates to medical decision-making capacities in these patients. Clinically, these findings suggest that poor verbal memory and expressive language function could serve as “red flags” for reduced consent capacity in this patient population, and, thus, signal that a more comprehensive medical decision-making capacity evaluation is warranted.

Decisions and attitudes regarding participation and proxy in clinical trials among patients with impaired cognitive function

“…Hence, cognition is per this description linked to both language and decision-making, which is in coherence with previous findings (e.g. Okonkwo et al, 2007;Gerstenecker et al, 2015). Nevertheless, the general study of linguistics covers a number of elements, discussed by for example Johansson and Manninen (2012).…”

“…Several previous studies (e.g. Gerstenecker et al, 2015;Grisso & Appelbaum, 1998;Dunn & Jeste, 2001) have showed that verbal function is associated to the decision-making capacity. Palmer and Savla (2007) underscored certain central abilities associated with the cognitive process of consent capacity, such as short-term memory (e.g.…”

“…• The 'understanding' component -executive function (Dymek, Atchison, Harrell, & Marson, 2001), processing speed, episodic memory (Okonkwo et al, 2008a), verbal function, fluency and memory (Gerstenecker et al, 2015).…”

Assessing Decision-Making Capacity in Patients with Communication Impairments

“…For example, it has been found that patient understanding varied directly with the vocabulary subtest of the Wechsler Adult Intelligence Scale, 19 , 20 and Gerstenecker and colleagues found that verbal memory and fl uency were highly associated with understanding as defi ned by the Capacity to Consent to Treatment Instrument. 21 These studies, although promising, still deploy neuropsychological tests that are reliant on expressive language. To apply these fi ndings to patients with communication impairments would require further research on neuropsychological tests that do not involve expressive language.…”

Clinical correlates of the ability to consent to research participation in brain metastasis

“…To accomplish this goal, we administered a comprehensive neuropsychological test battery and performance‐based measure of research consent capacity to all study participants. Based on our previous works, 1,8‐10 we hypothesize that impairments in the ability to provide informed consent would be largely driven by impairments on cognitive measures of verbal fluency and short‐term verbal memory. We further hypothesize that history of chemotherapy, steroid treatment, and anticonvulsant use would also be associated with the ability to provide informed consent.…”